Healthcare Provider Details

I. General information

NPI: 1033789672
Provider Name (Legal Business Name): MANDY DE BRUIN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2021
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 MEDICAL CENTER DR STE 100
HARDEEVILLE SC
29927-3452
US

IV. Provider business mailing address

PO BOX 604411
CHARLOTTE NC
28260-4411
US

V. Phone/Fax

Practice location:
  • Phone: 843-591-1390
  • Fax: 843-784-8297
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number24265A
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number24265
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN11013219
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberGAA-NP000003
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: